Mandatory Disclosure Advocated for Sleep-Deprived Surgeons

Surgeons coming off a busy on-call night should warn the next day's elective procedure patients that they've had little sleep and offer an opportunity to reschedule, a group of experts urged.

Institutions that don't prohibit a surgeon from operating after nearly 24 hours on the job, should require specific informed consent from patients scheduled to go under the knife, Michael Nurok, MD, PhD, an anesthesiologist at Brigham and Women's Hospital in Boston, and colleagues in sleep medicine and medical ethics recommended.

The same should go for acutely sleep-deprived anesthesiologists, according to their Perspective article in the Dec. 30 issue of the New England Journal of Medicine.

However, while agreeing that fatigue reduces cognitive and technical performance, the American College of Surgeons called mandatory disclosure unwarranted.

"We maintain that a call for mandatory disclosure essentially eliminates the necessary judgmental latitude surgeons should possess to determine their fitness for providing optimal patient care," David B. Hoyt, MD, and colleagues from the American College of Surgeons in Chicago, wrote in accompanying letter in the journal.

They cautioned about the slippery slope of requiring surgeons to disclose the number of hours they have slept, questioning whether disclosure of other personal factors that also negatively affect performance -- such as marital difficulties or financial worries -- would eventually be demanded.

Instead, Hoyt and colleagues recommended that surgeons be trained to understand the effect of fatigue on their capabilities and determine on a case-by-case basis whether to disclose their condition to patients, reschedule an operation, or seek assistance from another surgeon.

Nurok's group disagreed, warning that sleep-deprived clinicians are less able to accurately assess their impairment and the risk posed by performing procedures in such a state.

The culture of surgery long looked down on complaining about lack of sleep as a sign of weakness, commented David Cronin II, MD, PhD, a transplant surgeon at the Medical College of Wisconsin in Milwaukee.

Until there is an objective measure of performance in the OR, "the lack of awareness, denial, or lack of measured effect will keep from disclosure," he said in an e-mail to MedPage Today and ABC News.

They cited a study showing an 83% increase in risk of complications, such as massive hemorrhage, organ injury, or wound failure, in patients who have elective daytime surgery by attending surgeons who've had less than a six-hour opportunity for sleep between procedures during a previous on-call night.

Some institutions already have policies in place to keep physicians at busy practices from scheduling elective procedures on post-call days, eliminating the whole problem, Nurok's group pointed out.

"Such prohibitions should be standard practice," they wrote.

Where it isn't, they recommended, centers should at least have policies in place to facilitate priority rescheduling of elective procedures cancelled because of sleep deprivation and to at least require obtaining informed consent again for operations by a sleep-deprived surgeon.

However, there are plenty of barriers to such approaches, they acknowledged.

Informed consent in such circumstances places a burden on patients and may damage the patient-physician relationship, Nurok's group noted.

If the clinician discloses sleep deprivation but gets consent, any complication that occurs may raise suspicion of negligence secondary to sleep deprivation, Cronin added.

His approach has been to cancel elective surgeries without asking permission when too sleep deprived.

"Although disappointed, the patients were grateful for the disclosure and the understanding of the decision," he said in an e-mail.